Pathology/Lab Coding Alert

Learn what to expect from latest procedure limits

CMS won't publish the list of Medically Unlikely Edits (MUEs), but your lab won't get paid if you exceed the proscribed number of units.
 
MUE phase I passed with little notice because the January list included few 80000-level codes. But labs aren't so lucky with phase II (version 1.1), effective April 1, 2007.

Bone Up on the New MUEs

Background: Going from -unbelievable- to -unlikely,- the current MUEs are a refined version of the -Medically Unbelievable Edits- that CMS proposed -- and then withdrew due to provider concerns -- in 2005.
 
The goal: The new edits should prevent overpayments caused by gross billing errors, usually as the result of clerical or billing system mistakes, said Niles Rosen, MD, medical director for Correct Coding Solutions LLC -- which has worked with CMS to develop the current edits -- during a presentation at the American Medical Association's CPT and RBRVS 2007 Annual Symposium in Chicago.
 
What it means to you: -The MUEs will limit automatically the number of units of service you can bill for a service in any 24-hour period,- Rosen said.
 
Warning -- provider liability ahead: Unlike other Medicare denials for screening tests or based on National Correct Coding Initiative (NCCI) edits, you cannot bill the denied service to the beneficiary -- even with a signed Advance Beneficiary Notice (ABN), says Pamela Younes, MHS, HTL (ASCP), CPC, PA (ASCP), assistant professor at Baylor College of Medicine in Houston.
 
Updates: Like the NCCI edits, CMS will update MUEs quarterly and continually refine the list of procedures and the units.
 
For more information on the MUEs, read MLN Matters Number MM5495 at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5402.pdf.

Watch for More Subjective Edits

Learn anatomical edits first: The first batch of MUEs -- effective Jan. 1 -- focused on anatomically impossible claims. Most of the edits limited surgical procedures based on anatomy, such as only one appendectomy per day because a patient has only one appendix.
 
Code descriptors drive phase II edits: Phase II edits should include limits that the code descriptors clearly indicate, according to CMS. For instance, a lab edit that is effective April 1 is four units of 82784 (Gammaglobulin; IgA, IgD, IgG, IgM, each). That's because four is the maximum number of times you would report the code if the lab tested for all four immunoglobulins, based on the word -each- in the code definition.
 
Other phase II edits focus on the nature of the testing equipment, the study or procedure, or the pathology specimen, according to Younes. For instance, CMS sets the MUE limit for Pap smear codes at one because the nature of the specimen is a single cervical or vaginal smear in most cases.
 
This edit has already spurred debate, however, with the College of American Pathologists claiming that the limit should be higher because of circumstances such as Diethylstilbestrol (DES) exposure that require separate sampling of the cervical transformation zone and the vagina for Pap testing (CAP Statline Nov. 30, 2006).
 
Medically reasonable limits are next: You can expect even more subjective limit-setting in MUE phases III and IV as CMS begins adding edits based on -medically reasonable limits.-
 
Some of the April 1 edits already seem to fit this category of medically reasonable limits, according to Younes. For instance, phase II edits include 85097 (Bone marrow, smear interpretation), which the MUE limits to two. But for cancer staging, a pathologist might examine three smears in one day -- from bilateral iliac crests and the sternum.

Appeals or Modifiers -- That Is the Question

Many providers are asking what they should do when facing a claim denial based on these new edits. -First of all, you will be hard-pressed to know that Medicare is denying a claim based on an MUE edit, because CMS refuses to release the MUE tables to the provider community,- says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology-business-practices publishing company in Simpsonville, Ky. 
 
Appeals: For non-institutional providers (such as pathologists and independent labs), Medicare carriers will deny the claim line that exceeds an MUE edit but pay the rest of the claim -- and the provider can appeal, according to CMS- instruction in MLN Matters Number MM5495.
 
-Based on the official instruction and my conversations with John Stewart at CMS, your best bet is to appeal -- not only to get the individual claim paid but to provide input about how MUE limits should be changed,- Younes says.
 
But for institutional providers such as hospitals, Medicare will -return to provider (RTP)- the entire claim and not allow an appeal, according to the MLN article.
 
-The instruction goes on to tell institutional providers to figure out why Medicare returned the claim, correct the error and resubmit -- but how can the hospital determine what exceeds the MUE limit when the limits are secret?- Padget asks.
 
Modifiers: No official guidance indicates that you can use modifiers to override MUE edits as you can for NCCI edits when medically necessary. However, in a publicized March 5 letter to CMS, CAP documents receiving direction from the MUE contractor to use modifier 59 (Distinct procedural service) to report additional specimens.
 
CAP asks, -How will a physician know to use a modifier to override the MUE if he does not know what the MUE limit is?-
 
You can access the letter from the link in the April 12, 2007, Statline available at www.cap.org.